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Competition License Application Please read instructions on back before completing application. Change of Address? Exchange of Region of Record? Exchange of Division? Displease refer to: GCR 3.9.1
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To fill out an examination and medical history, follow these steps:
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Start by providing your personal information such as your full name, date of birth, address, and contact details.
03
Indicate any previous medical conditions or surgeries you have had, along with the dates and any relevant details.
04
Specify any current medications you are taking, including dosage and frequency.
05
List any known allergies or adverse reactions to medications or substances.
06
Provide details about your family medical history, such as any hereditary conditions or diseases that run in your family.
07
Mention any lifestyle factors that may impact your health, such as smoking, alcohol consumption, or regular exercise.
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Describe any recent symptoms or concerns you have been experiencing, along with their duration and severity.
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Don't forget to sign and date the examination and medical history form before submitting it.

Who needs examination and medical history?

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Anyone who is seeking medical attention or undergoing a health evaluation needs to fill out an examination and medical history form. This includes individuals visiting a new healthcare provider, going for a regular check-up, or seeking specialized medical treatment. Providing accurate and comprehensive information about your medical history is crucial to help healthcare professionals make informed decisions about your care and treatment options.
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Examination and medical history refers to the systematic collection of information regarding a person's past and present health status, medical conditions, treatments, and overall physical examination results.
Individuals seeking certain medical services, insurance policies, or employment in health-related positions may be required to file their examination and medical history.
To fill out examination and medical history, individuals should provide accurate and complete information by answering all questions on the form, disclosing past illnesses, surgeries, medications, and family health history.
The purpose of examination and medical history is to assess an individual's health status, identify risk factors, guide clinical decisions, and ensure appropriate care and treatment.
Information that must be reported includes personal identification details, medical conditions, medications taken, allergies, prior surgeries, family health history, and any relevant lifestyle factors.
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